Provider Demographics
NPI:1811542269
Name:LAKE, LAWRENCE LELAND (CRNP)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:LELAND
Last Name:LAKE
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 MOONLITE DR
Mailing Address - Street 2:
Mailing Address - City:ODENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35120-5463
Mailing Address - Country:US
Mailing Address - Phone:205-441-1483
Mailing Address - Fax:
Practice Address - Street 1:701 PRINCETON AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1303
Practice Address - Country:US
Practice Address - Phone:205-783-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-127139163WE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency